Developments With Gastrointestinal NETs Continue to Grow

Danielle Bucco

Published: Friday, Jan 05, 2018

Diane Reidy-Lagunes, MD

2017 was an important year for patients with neuroendocrine tumors (NETs). Diane Reidy-Lagunes, MD, said the phase III NETTER-1 trial comparing Lutathera (lutetium [177Lu] oxodotreotide) plus best supportive care versus octreotide (Sandostatin) LAR was a significant development in the treatment of patients with advanced midgut NETs.

OncLive: Please provide an overview of your presentation on GI and pancreatic NETs.

Reidy-Lagunes: I gave an overview on the treatment of NETs, which is changing quickly, but also how you diagnose and define the patient and develop personalized medicine.

One of the struggles with our disease is that it is quite heterogeneous. How you define and care for a patient depends on multiple factors. I gave an overview on how one can define appropriate treatment. Unlike other malignancies, this is a cancer that does not have sequencing trials of what therapy should be given first, second, or third. It depends on the different patients that you are treating.

Currently, what challenges do we have with diagnosing NETs?

The good news is that we are finding these tumors but we hope we can find them earlier, which will translate into overall improvement and hopefully more cures. We have not yet figured that out though. Eventually, our data will tell us that, but we know that incidence is increasing at an exponential rate. We believe that is because we are picking them up. The hope and expectations are discovering it earlier, which will translate to better outcomes.

Many patients are still developing metastatic disease. We do not have any markers or ways to screen for these tumors, unfortunately. When a patient goes for general screening for a colonoscopy, a big take-home message is to try to push through into the terminal ileum because that is one of the most common places that NETs can hide. By doing that, we are picking out more terminal ileum masses that turn out to be carcinoid or NETs. That unquestionably will increase the chances of cure.

From that perspective, endoscopies and rectal NETs are being picked up earlier, which is great. Upper endoscopies that are being done for other reasons are incidentally finding these tumors. There are many opportunities through endoscopy but we still have not defined lung NETs or pancreatic NETs because there is no real screening for those.

Looking back on 2017, what are some of the exciting advancements that you have seen with NETs?

It has been a great year for NETs since there have been a couple of treatments that have increased either by quality or quantity. Peptide receptor radionuclide therapy was a home run in this field. The NETTER-1 trial took patients that had already received octreotide, which is our first-line therapy, and randomized patients to higher-dose octreotide and Lutathera peptide receptor radionuclide therapy.

We do not usually get numbers like that in oncology. The hope and expectation is that patients with somatostatin avid disease will benefit from this. That study was only in midgut disease, so it is at the FDA now for consideration of treatment with Lutathera for any patients with somatostatin avid disease, whether it is small bowel or in all-comers who have NETs. It is a major milestone.

There are rare and serious adverse events that we need to consider. There is a rare risk of myelodysplastic syndromes and leukemia but patients generally can get tremendous benefit.